In the second installment of In-depth with the Evidence Project, Kate Gilles talks to Population Council Associate Aparna Jain about a recent study she and fellow Evidence Project colleagues conducted in Bangladesh on how contraceptive side effects impact women’s lives. Jain describes how side effects influence women’s daily work, family relationships, and religious life, and how those experiences may influence their future contraceptive choices.

With a guest appearance from Dr. Ubaidur Rob, Population Council Country Director in Bangladesh, this insightful new episode highlights the importance of listening to women’s voices and helps think creatively about how to respond to women’s needs.

In-depth with the Evidence Project brings you conversations with Evidence Project researchers about how the USAID-funded project is applying implementation science to advance quality family planning and reproductive health programs internationally. Each episode explores the principles, process, and impact of implementation science and takes a deeper look at the project’s studies, asking questions like: “How can we expand access to family planning for garment factory workers in Cambodia?”; “Why is the public sector so critical to family planning in Zambia”; and “What makes implementation science unique and why does that matter for family planning?”

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Kate Gilles

Welcome to In-depth with the Evidence Project. I’m Kate Gilles, Senior Communications Specialist with the Evidence Project. In this podcast series, I’ll be talking to Evidence Project researchers about how they’re using implementation science to transform and improve family planning programs around the world.

In today’s episode, I speak with Aparna Jain, and associate with the Population Council, about new results from a study in Bangladesh.

I’m talking today with Aparna Jain. Aparna, I'm going to have you introduce yourself - you’ll do it best!

Aparna Jain

Thanks, Kate. my name is Aparna Jain and I'm an Associate at the Population Council, and I work primarily on the Evidence Project.

Kate Gilles

Thank you so much for coming in. And I invited you to do the podcast today after I saw a manuscript that you and some colleagues on the Evidence Project just put out. The title of the article is Side Effects Affected My Daily Activities a Lot. I've read the article, but some people in our audience probably won't have… I know a little bit about what led up to the study, but I'd really like to hear from you where the idea from the study came from and what you guys were looking at.

Aparna Jain

Sure. So, when we, when we think about contraceptive use and we think about discontinuation, side effects tends to be one of the leading causes of discontinuation. The ways in which side effects have been studied or measured tends to primarily be on the side of physical manifestations of side effects. So, for example, you know, discharge, pain, irregular bleeding. But yet we don't know very much about how women internalize the side effects and the ways in which it may affect their daily lives.

So, this research basically came out of a need to do some qualitative work around understanding "What do side effects actually mean to women?" and getting information from women's voices and hearing what their stories were, since most of the work has been on the quantitative side.

Kate Gilles

And thinking how does the woman experience that? And then what does that mean for her daily life?

Aparna Jain

Exactly. So how does that get interpreted into the different things that she is able or unable to do, and then how does that subsequently affect her relationships with her family, her husband, her in-laws, her children? Are they willing to support her when she experiences side effects? What does that space look like for a woman and how does she then take those experiences, and do they influence her decisions around continuing a particular contraceptive method, stopping using it or switching to another method?

We conducted in-depth interviews with recent discontinuers and method switchers in two divisions in Bangladesh, Khulna and Sylhet. So, a discontinuer is a woman who stops using a contraceptive method, and a switcher is a woman who switches from one method to another method. We asked them qualitatively, what types of side effects they experience. We interviewed women who had been using the pill, injectable, the IUD, and implants.

What we found was that the majority of women reported that they experience physical side effects. In addition, though, they also reported that they, that the side effects influenced spheres of their lives.

So, the three themes that we found from the study were that side effects influenced women's participation in their religious life. It influenced their participation in household chores and, and their daily life, but then also influenced their sexual life. So, these were the three spheres or domains of life that side effects appeared to have affected in Bangladeshi women.

Kate Gilles

When I was reading the article, I thought the quotes from the transcripts were really powerful. The thing that really struck me was the way the women described how they experienced the side effects. It wasn't just ... These weren't just nuisances. This wasn't just like, "Oh, it's sort of irritating that I have to deal with an additional day of bleeding."

Aparna Jain

Mm-hmmm (affirmative).

Kate Gilles

Some of these side effects really, you know, had pretty serious impacts on either their ability to do their daily activities…their, as you mentioned, participation in religious life. And sometimes, there were pretty severe consequences that sort of folded out from that. Can you talk a little bit more about that and, you know, the implications then for family planning use?

Aparna Jain

We were really ... We didn't know what to expect with this inquiry of research, and so we were very open to listening to what women reported and listening to their stories. And so, what we found was that yeah, these side effects and the implications of these side effects on women's participation in the work that they're usually accustomed to doing really impacted the ways in which they were able to continue to do that work.

So, for example, one woman had said that she couldn't prepare the food in time when her husband and her father-in-law came back from the paddy fields, because she was experiencing side effects and she also had to take care of her children. When she didn't have food available for her husband and her father-in-law, when they came home, they scolded her. So, she experienced some levels of verbal abuse, which, of course, in order to avoid, one may decide to stop using contraception.

Kate Gilles

As I was reading this, I thought about ... It seems like, you know, when the side effects are as extreme as some of these women experience…at some point, maybe the priority of avoiding those side effects becomes greater than the priority of avoiding an unintended pregnancy. What are your thoughts around that?

Aparna Jain

It's certainly….it's certainly a hard question. We didn't ask about that, but we do know that a quarter of all unintended - no, actually, a third of all unintended pregnancies are the result of a contraceptive discontinuation. So that's a pretty staggering number in, in my opinion, and I think that there are women who will choose to experience an unintended pregnancy or have the - take the risk of an unintended pregnancy versus the experience of side effects.

Kate Gilles

Right.

Aparna Jain

What this means for programming, though, is that as providers, when they provide counseling around different contraceptive methods, typically go through the advantages, disadvantages, effectiveness, of the contraceptive method, so that women are able to make an informed choice, these additional aspects associated with side effects could be also included in their counseling. If their client is highly religious, for example, and they select a method that is known to have irregular bleeding patterns, it's something that a provider could inform a client about, to say, "If these irregular bleeding patterns start to influence your life in a way that you're unable to manage them, return back to the clinic. Come back and see me. Let us reexplore all the different contraceptive methods that are available, and make sure that we are meeting your needs for avoiding an unintended pregnancy, but then also having a, a healthy, comfortable life while using contraceptive methods.

Kate Gilles

I also spoke with Dr. Ubaidur Rob, Population Council’s Country Director in Bangladesh and one of the investigators on this study, to hear more about what the results mean for family planning programs in Bangladesh.

Ubaidur Rob

My name is Ubaidur Rob. I am Country Director of Population Council in Bangladesh.

Bangladesh has reached replacement level fertility and contraceptive use rate is significantly high in this country for the last five to six years. Most of these methods are temporary methods, and that created a problem for family planning programs in Bangladesh: approximately one-third of acceptors drop their existing method within one year of their acceptance and at the same time, one-third of the total pregnant mothers reported that they become pregnant due to unintended or unplanned pregnancy. We found that the contraceptive discontinuation rate, particularly oral pills and IUDs, is significantly contributing to this unintended and unplanned pregnancy. And the reason they are telling that they are dropping or discontinuing, is due to side effects. But we don’t have any detailed information from these users. This study was intended to find out why the women are discontinuing this method due to side effects.

Kate Gilles

I’d like to hear your thoughts on how you can use this information to help improve contraceptive services and contraceptive use in Bangladesh.

Ubaidur Rob

We have already shared this information with the Directorate General of Family Planning, who are the primary supplier of contraceptive methods in the rural areas and also in the urban areas. The detailed qualitative information from this study will help the Ministry of Health and Family Welfare to redesign their training, particularly educating their field workers.

Kate Gilles

I asked Aparna what she wants listeners to know about what this study means for individual women.

Aparna Jain

It's thinking about ensuring that women have the choice and the means to, to remain on contraception if that's what they choose.

Kate Gilles

And that they're not having to make a compromise between putting up with a side effect that really interferes and achieving their reproductive goals.

Aparna Jain

No, but that's really it. Women shouldn't have to make those choices.

Kate Gilles

I know that you guys are building on this research. So, I'd love to hear ...

Aparna Jain

Sure. You know, I think this is one of the few times that we're actually getting at women's own voices around the effects of side effects, and we're moving beyond kind of pushing it off to the physical manifestations. So, under the Evidence Project we're conducting a study in India where we're following injectable pill and IUD users over the course of one year to look at their contraceptive use dynamics. Given that we know side effects are a leading cause of discontinuation, we've taken the results from this study in Bangladesh and developed questions - specific attitudinal questions - around whether the side effects influenced women in these particular spheres of life.

We've also added some questions in relation to how side effects influence employment and how side effects influence participation in education as well, and so what we're really looking to do is to see whether we can quantify it. By quantifying it, we can then predict how do side effects influence continuation of a particular contraceptive method, but generally, overall contraceptive use. That's what we're basically concerned with. And then what the role is of the healthcare system and then what the role is of, potentially, their, their support system - like their husbands and their social networks - to see if those are influencing factors as well.

Kate Gilles

Where is that study in the pipeline? And then when should people look for the results of that one?

Aparna Jain

So that study's still ongoing. We are in the process of, of recruiting and enrolling women, still, but right now, we have over 2,000 women enrolled in the study, and probably a good portion of them have already been followed up, so we're going start doing the analysis and looking into some of these issues that we've been talking about, but my guess, it'll take a year.

Kate Gilles

The Evidence Project is funded by USAID. It’s led by the Population Council with partners INDEPTH Network, International Planned Parenthood Federation, PATH, and Population Reference Bureau.

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The Evidence Project seeks to expand access to high quality family planning/reproductive health services worldwide through implementation science, including the strategic generation, translation, and use of new and existing evidence. The project is led by the Population Council.